Hospital Casemix Protocol data provide a brief summary outlining
morbidity data and costs associated with an episode of care. Federal
government legislation requires that hospitals report this information
to private health insurers who, in turn, merge these data with benefit
outlays and report their findings to the Department of Health and Ageing
(DoHA). This article gives a brief outline of the collection, cleansing
and processing of these data and subsequent reporting to DoHA by
Medibank Private, which accounts for approximately 30% of collected
data.

The Commonwealth Department of Health and Ageing (DoHA) legislation
stipulates that each private hospital and day-care facility in Australia
(of which there are over 400) submits Hospital Casemix Protocol (HCP)
data (a summary of a patient's admission) for privately insured
patients to the appropriate health fund within six weeks from the end of
the month of separation. The HCP file is comprised of a header line that
includes hospital and fund IDs, the period of reporting, number of
records, HCP version and ICD10-AM coding version. Further, each line of
data in the HCP file represents an episode of stay for a patient and
contains the patient's details such as name, date of birth,
postcode and fund membership ID, which are used by the fund to match the
record to data in the fund's claims database. Other information
included are various charge items, morbidity details and other
administrative data relating to the patient's episode of care.

Also required from hospitals with a registered rehabilitation
program is Australian National Sub-Acute and Non-Acute Patient (AN-SNAP)
data, which summarise the rehabilitation admission. These data are
similar in structure and include functional impairment scores. The
specifications for the format of these files can be found at
http://tinyurl.com/ HCPspecHtoFund0910.

Hospital submission

Data for both Medibank Private Limited (MPL) and Australian Health
Management (AHM) arrive via one of three channels: secure web portal,
email or diskette. The secure web portal is an MPL innovation, which
allows hospitals to submit their data with full 128-bit encryption to
ensure the privacy of patients and their details. For this reason, it is
MPL's preferred approach and somewhere between 80% and 90% of data
arrive via this channel. Most of the balance comes via email, some of it
zipped and password protected, with only a handful of facilities still
using diskettes and the postal service.

Initial processing at MPL

When a file is received via the web portal, the system scans the
file and does a preliminary check to see if the file is basically
formatted correctly and the fund ID is MBP (1) or AHM (the defined fund
IDs as per DoHA specification). The details of the header line from the
file are then broken out into their component fields, labelled and then
emailed back to the registered email address. The transaction is also
logged for an audit trail.

Data that arrive via email or diskette are treated in the same way.
Any files that do not pass initial scrutiny are rejected and deleted and
an email is automatically sent to the facility with header details and a
reason for the failure in the same way the web portal does. The arrival
of all files and their mode of transport are logged at this point as
well.

Editing

Once a day, the files uploaded to the web page are downloaded to
MPL for processing and edit checks. All files collected for the day are
then run through the 3M grouper and grouped to versions 4.2, 5.0 and
5.1. The files are then uploaded into a Microsoft SQL Server database
for edit checks and further processing. MPL performs all edit checks
listed in the specification, plus a few additional checks that include
an algorithmic check on the membership ID and a match of the DRG
supplied in the file to the appropriate DRG obtained by the 3M grouper
mentioned earlier. This means that if the hospital 'groups' in
DRG Version 4.2, then their result is compared with Version 4.2 results
obtained at MPL (2).

Any data anomalies are assigned an error code and logged. Data that
are anomalous, but do not have an impact upon the quality of the HCP
submission according to the specifications are assigned a W type error
code or WARNING ONLY. Fatal errors are assigned an E type code. Any
record that attracts an E type error code is deleted for privacy and
security reasons. DoHA has deemed that any submission (month) with more
than a 5% error rate shall fail and the month considered as not having
been submitted. Only fatal errors count to this error rate.

A summary of errors is logged in the database and an error report
emailed to each facility. If there are no errors to report, then the
facility is emailed with this result also. A follow-up flag is placed
against each month of data for each hospital where there are errors that
need correction. If the data are not submitted within four weeks of the
error report being sent, a reminder email is sent. A further reminder is
sent two weeks later if there has still been no re-submission.

At around the 14th day of each month, a report is generated for
each facility listing all months in the previous 12-month period where
data have not been received or the error rate remains above the 5%
threshold. This report is automatically emailed to each facility in
default of the rules. Two weeks after this report has been sent, a
similar report is generated for those facilities where action has not
been taken. This report is then sent to DoHA as required.

All data that pass edit checks are stored on a secure, restricted
access SQL server. Any duplicate records from re-submissions are updated
to the newest submission and the old record deleted to prevent
duplication.

HCP and billing claims

Once a month, the HCP data are matched up with data in the claims
database to connect benefits paid with the charges. These data are
de-identified and forwarded on to DoHA as stipulated in legislation.
Amendments are submitted to DoHA for six months to include any late
data.

Data analysis

HCP data also has its uses at MPL internally. Two major areas of
use at MPL are in 'Better Health Management Programs' and
Hospital Modelling. All analysis in these areas is done on de-identified
views of the hospital data. The Benefit Analytics Department at MPL uses
the HCP data to analyse overall hospital benefit outlays using casemix
techniques, looking for growth in clinical areas and variations in
clinical service delivery by geographic area.

MPL also models individual hospital activity in terms of changing
length of stay and readmissions. This information is used by the
hospital contract managers in their negotiations with hospitals. MPL use
an episodic payment system, Price Weight of One (PWO), with our
contracted private hospitals. In this system we pay an agreed fee for
hospital separations as per the allocated ARDRG. MPL uses the National
Hospital Cost Data Collection (Department of Health, Canberra) to weight
the complexity or resource usage of the separations with the ARDRG to
determine a price. This is then included under our contract with the
hospital as a payment schedule.

MPL aims to provide its members with more than just health
insurance. The Health Management team, which includes a doctor, nurses,
HIM and other medical specialist professionals, focuses on helping
members achieve better health and wellbeing. This is achieved by
developing programs for members to support them in losing weight, making
healthy food choices and management of chronic health conditions. Trends
analysis of HCP data assists in the development of these programs.

(1) While MPL has been used to denote Medibank Private Limited
throughout most of the document, the current HCP specification has the
fund ID for Medibank as MBP. This will change to MPL on 1 July 2010, to
bring the HCP specification into line with Eclipse. For the moment it
remains as MBP

(2) When 'grouping' a record to a DRG there are several
versions that a hospital can group to. Many still group in Version 4.2
while others group to Versions 5.0 or 5.1 with Version 6.0 about to
become another option.